Fillable HCV Recertification Packet

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HCV Recertification Packet

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Housing Choice Voucher Program
200 Ross Street, Suite 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
Dear Section 8 Participants:
Thank you for choosing the Housing Authority of the City of Pittsburgh (HACP) to be
your housing provider. It is the desire of the HACP to provide you with outstanding
customer service, to process your paperwork in a timely manner and to provide you with
safe and affordable housing.
Please be advised that our re-certification process is a twenty-four (24) month recertifica-
tion process. When you receive a Recertification Packet, please immediately complete
and return the Packet to your Housing Specialist with the requested information. Please
note failure to return the information in the requested time may result in termination from
the Program. As such, even if you think your recertification is not due, and you receive a
Recertification Packet, you must complete and return the Packet as requested.
If you are a person with a disability and require information regarding reasonable
accommodation, please contact the 504 ADA Compliance Office at 412-456-5282. Thank
you again for allowing the Housing Authority of the City of Pittsburgh to supply your
housing needs.
Sincerely,
Director, Housing Choice
Voucher Program
Housing Authority of the City of Pittsburgh
Housing Choice Voucher Program
Recertification Packet
Table of Contents
1
Recertification Checklist
2
Request/Verification for Reasonable
Accommodation for Live-in Aide
3
Employment Status Verification
4
Verification of Employment and Gross Earnings
5
Verification of Childcare
6
Family Composition & Utility Information
7
Applicant/Tenant Certification
8
*Supplement to Application for Federally Assisted
Housing – Attachment A
9
HCV Application
10
Asset Checklist
11
HUD Form 9886 – Authorization for the Release
12
Self-Certification Form (Assets of less than
$5,000)
13
*Debts Owed – HUD Form 52675
14
*Family Obligations
15
RSS Flyer
16
Resident Employment Program
17
Assistance For Persons With Disabilities
* Two Copies (1 for HACP; 1 for Participant)
(Documents 10, 11 & 13 must be signed by each household
member 18 years and older.)
RECERTIFICATION CHECKLIST
VERY IMPORTANT
IF YOU DO NOT HAVE ALL OF THE REQUIRED INFORMATION, YOU WILL BE
SENT A NOTICE OF WHAT INFORMATION IS MISSING, AS WELL AS A NOTICE
OF TERMINATION. YOU MUST IMMEDIATELY PROVIDE THE REQUESTED
INFORMATION OR YOU WILL LOSE YOUR SUBSIDY IF WE CANNOT RECERTIFY
YOUR FAMILY BY THE EFFECTIVE DATE!!!!!
Requesr/Verification for Reasonable Accommodation for Live-in Aide (If applicable)
____
Income Verifications for all household members (Wages, TANF/DPA, Child Support, SSI, Social
Security, Pension, Unemployment, etc.). Provide all Current Printouts and/or 6 Consecutive Pay
Stubs.
____
Childcare Verification
____
Family Composition Form
____
Signed Applicant/Tenant Certification (Fraud) Form
____
Attachment A/HUD 92006 Optional Contact Information (2 copies)
____
Asset Verification (Bank Statement – Checking & Savings), Stocks, etc. Provide Current
Statements.
____
Annual Continued Occupancy Form (ACO)
____
***Signed Authorization of Release of Information (HUD Form 9886)
____
***Debts Owed to Public Housing Agencies and Terminations – Form HUD 2675 (2 copies)
____
Family Obligations (2 copies)
____
Medical Expense Verifications for disabled/elderly (62+) households
____
Zero Income Affidavit (if applicable). Please contact Housing Specialist for forms.
____
Full-time Student Status – For Dependents 18 years of age and older, provide letter from the
Registrar’s Office verifying full-time student status or a copy of student’s current schedule.
____
Provide Current Statements/Verifications.
____
____
***Must be signed by each household member 18 years and older.
All forms must be completed in ink, and packets must be dropped off or mailed into the office.
Faxed Copies will not be accepted.
**PLEASE BE SURE THAT THE ITEMS LISTED ABOVE ARE ENCLOSED BEFORE
RETURNING YOUR RECERTIFICATION PACKET**
Disability Co
mpliance Office
100 Ross Street, 4
nd
Floor
Pittsburgh, PA 15219
Telephone: 412.456.5282
TTY 412.201.5384
Facsimile: 412.471.0964
Dear Housing Choice Voucher Participant:
Please be advised the following Reasonable Accommodation Verification Form - Request for Continued Approval of Live-In
Aide Housing Choice Voucher (HCV) Program form is being provided to verify your continued need for a Live-in Aide. To
confirm this, we will need third party verification of your continued need for this request. Please know HACP never
inquires into the nature or extent of your disability. The HACP requires verification of how your request is related to your
disability and how it will remove a barrier(s) you face in housing.
IF:
• YOU WERE NOT PREVIOUSLY APPROVED FOR A LIVE IN AIDE VIA REASONABLE ACCOMODATION, OR
• YOU WERE PREVIOUSLY APPROVED FOR A LIVE IN AIDE VIA REAONABLE ACCOMODATION BUT THE PERSON
YOU SUBMITTED TO HACP FOR LIVE IN AIDE APPROVAL HAS NOT BEEN APPROVED BY HACP
DO NOT fill out the following Reasonable Accommodation Verification Form - Request for Continued Approval of Live-In
Aide Housing Choice Voucher (HCV) Program form. If you would like to submit a reasonable accommodation request for a
live-in aide, please contact your housing specialist.
Once HACP receives the completed verification form back from your Third Party Professional, we will review your
request. Please return the completed form regarding your disability related need within 15 days from the date you
submitted your annual reexamination packet to HACP.
Please be advised that if there are any changes in the person that has been your live-in aide, you will need to immediately
report these changes to your Housing Specialist so the new person can undergo the HACP formal verification process
before they can be added as your Live-in Aide.
Your Housing Specialist is unable to provide you with assistance regarding your live-in aide request prior to:
• the Reasonable Accommodation form being completed in full by you and your Third Party Professional,
• the completed Reasonable Accommodation Request form being submitted to HACP for review and approval by
the Disability Compliance Office.
If you have any questions, you may contact the Disability Compliance Office at 412-456-5282.
Sincerely,
Housing Authority of the City of Pittsburgh
Disability Compliance Office
Disability Compliance Office
100 Ross Street, 4
nd
Floor
Pittsburgh, PA 15219
Telephone: 412.456.5282
TTY 412.201.5384
Facsimile: 412.471.0964
REASONABLE ACCOMMODATION VERIFICATION FORM
REQUEST FOR CONTINUED APPROVAL OF LIVE-IN AIDE
HOUSING CHOICE VOUCHER (HCV) Program
Instructions (please review carefully)
(1) The individual or family member should describe in detail the continued need for a Live-in Aide.
(2) The Third Party Professional (such as a doctor/nurse, social worker, or service agency counselor) should
initial this request if, in their opinion, it has been determined the need still exists due to the individual’s or
family member’s disability. Attach supplemental information if necessary for any requests. Do not include any
information about the nature or extent of the person’s disability. DO NOT SEND MEDICAL RECORDS.
(3) The third party professional “MUST” complete and sign the form as directed.
(4) All requests with complete verification documents will be responded to within 30 days of receipt of the
completed documents. If the request is denied information will be provided on the right to grieve the denial.
(5) Please note: this form should be returned within 15 days from the date the requester received it.
Please Complete Release of Information:
Participant ______________________________________ Date of Birth: ______________
(Print the name of the person with the disability)
I currently reside at______________________________________________________________________.
(Print patient’s full address:)-street apt. no. city state zip code
My phone # ______________________ Name of the Head of Household ___________________________
By signing this release, I authorize __________________________________________________________
(Name of Third Party Professional, i.e. nurse, social worker, doctor)
to release information to the HACP to verify my disability and the need for an accommodation.
Participant/Guardian (sign name) ________________________________ Date: ___________
*If this is for a child with disabilities please print Guardian’s name ________________________________
and Guardian should sign above.
If you are in need of additional assistance or an alternate means of reviewing and understanding this
process, please contact the Disability Compliance Staff at 412-456-5282.
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Disability Compliance Office
100 Ross Street, 4
nd
Floor
Pittsburgh, PA 15219
Telephone: 412.456.5282
TTY 412.201.5384
Facsimile: 412.471.0964
NAME OF PARTICIPANT: _____________________________________________________
EXTRA BEDROOM FOR LIVE-IN AIDE: This individual requires a specific person to provide LIVE-IN
assistance related to a disability (not just visiting help). This process is not to be used as verification for aides
who come and go on a rotating basis, such as a caregiver(s) that works specific shifts during the day or night. A
live-in aide must meet this HUD definition: A live-in aide is a person who resides with one or more persons
with a disability and who: (1) Is determined to be essential to the care and well-being of the person(s); (2) Is not
obligated for the support of the person(s); and (3) Would not be living in the unit except to provide the
necessary supportive services. Please describe the duties of the aide below and initial.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name of the Live-In Aide:____________________________________ Professional Initial Here: ___________
FOR PROFESSIONAL TO COMPLETE
In my professional opinion, the above individual a) has a disability as defined below which creates a barrier to
access HACP housing/housing assistance and related programs and services, and b) the requested special
features, modifications, and/or change(s) to HACP policy(s) listed above are required to address those barriers
in order to allow the above individual full access to HACP housing and related programs and services. The Fair
Housing Act defines a person with a disability as (1) individuals with a physical or mental impairment that
substantially limits one or more major life activities; (2) individuals who are regarded as having such an
impairment; and (3) individuals with record of such an impairment.
Name (print):__________________________________________________________________
Title:_________________________________________________________________________
Organization Name and Address:__________________________________________________
Phone:____________________ Fax:_________________ Email: ________________________
Person to contact with questions about form:_____________________________________
I certify that the information I am providing is accurate and true to the best of my knowledge based on
my professional training and experience.
Signature of Professional:___________________________________ Date:________________
The certifying professional should return this form to:
HACP - DISABILITY COMPLIANCE OFFICE
Fax Number: 412.471.0964 or Email: ra@hacp.org
Note: It is important that all pages (2) need to be completed and returned within 15 days from the date the
requester received them.
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Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
EMPLOYMENT STATUS VERIFICATION
____________________________________
Applicant/Participant Name
Dear Employer:
Regulations require us to verify the incomes of applicants and tenants to establish their eligibility and rent for
our Rental Assistance Housing Program. The person identified on this form has told us that he or she is now
employed, or has been employed by your firm.
Your completion of this form will help us to determine whether this family is eligible for our housing program.
All information will be held in confidence and will be used only in determining eligibility and/or rent and rental
subsidy.
We are required to complete our determination within a specified time; therefore, your prompt reply will be
appreciated. A return envelope is enclosed for your convenience.
Thank you for your cooperation.
_____________________________________ _____________________________
Employer’s Name Employer’s Phone No.
_____________________________________
Employer’s Address
_____________________________________
City, State, Zip
AUTHORIZATION TO RELEASE INFORMATION
I hereby grant the Housing Authority of the City of Pittsburgh permission to make inquiries regarding
my income and assets. I understand that this information is for the purpose of determining my eligibility
only, and will be kept confidential.
Signed: ______________________________________
Date: ______________________
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Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
VERIFICATION OF EMPLOYMENT AND GROSS EARNINGS
In
accordance with federal law and regulations published by the Department of Housing and Urban Development, it is
necessary to verify the sources and amounts of income of each family making application for or receiving rental
assistance. Information provided remains confidential and will be used solely for the purpose of determining eligibility
for rental assistance and establishing rent in accordance with applicable law and federal regulations.
The
following individual has indicated employment with your firm. To assist in the compliance with the above
provisions, you are requested to provide the following information:
Em
ployee Name: ______________________________ SS# ________________________________
Presently Employed: YES _____ Date Employed _______________________
NO _____ Date Terminated_______________________
Fu
ll Time _____ Part Time _____ Title/Position _________________________
BAS
IS OF PRESENT PAYMENT
Present hourly rate base pay: $__________
Hours per day ________ Number of days per week _______ Average hours per week _______
Pr
esent hourly rate, overtime $__________
Weekly wage or salary $__________
Monthly Salary $__________
Piece Work: (average) $__________
Commission: (average) $__________
Any other compensation not included above (specify for meals, expense allowance, etc.)
For ________________________ $__________ per _______________________
Tip-estimate $__________ Anticipated earnings next 12 months. $ ____________
Amount (if any) deducted from earnings for Medical/Hospitalization Insurance
$__________ per __________ (week, bi-weekly, monthly, etc.)
What address do you have in your records for your employee?
_______________________________
_______________________________
_______________________________
_______________
_______________________ ________________________________________
Employer Employer Signature
____________________________________ ______________________________________
Date Title
20___ Gross Income $_____________
20___ Gross Income to Date $__________
PLEASE COMPLETE EACH QUESTION
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Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090; fax 412-456-5224
TTY: 412-201-5384
www.hacp.org
VERIFICATION OF CHILDCARE
Name: ______________________________
Address: ______________________________
Contact No.: ______________________________
TO BE COMPLETED BY TENANT
This is to certify that I pay to _____________________ $________ per we
ek for
the care of my child/children while I am employed or while attending school.
Signed: _______________________________ Date:________________
Are you being reimbursed for childcare from DPA or any other Agency?
Yes ____ No ____
TO BE COMPLETED BY CHILDCARE PROVIDER
This is to certify that I receive $________ per week from _____________________
for childcare services.
Names of Children Age
__________________________________ _______
_____________________________ _______
_____________________________ _______
Signed: ______________________________ Date: ____________________
Address: _____________________________ Phone: ___________________
______________________________ S.S.#: ____________________
____________________
PLEASE NOTE:
CERTIFICATE STATEMENT
Knowing the penalty for making a false statement under the United States Criminal Code I hereby
certify that the above is a true and full statement.
Section 35(a) of the United States Criminal Code makes it a criminal offense, punishable by the maxi-
mum of 10 years imprisonment, $10,000 fine or both, to make false statement or misrepresentation of any
department or agency of the United States as to any matter within their jurisdiction. The information
provided above was requested by the Housing Authority of the City of Pittsburgh as a verification
document.
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Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090; fax 412-456-5224
TTY: 412-201-5384
www.hacp.org
FAMILY COMPOSITION & UTILITY INFORMATION
PLEASE ANSWER ALL QUESTIONS
1) What type of heating do you have in your unit?
Electric Heat _______ or Gas Heat_______
Do you pay for heating? Yes _____ No _____
2) What type of range do you have? Gas _______ Electric _______
Do you pay Cooking Gas? Yes _____ No _____
3) Do you pay for electricity? Yes _____ No _____
4) Is your hot water heater Gas _____ or Electric _____
5) Do you pay for Water _____ Sewage _____ Trash _____
6) Do you own the range in your unit? Yes _____ No _____
7) Do you own the refrigerator in your unit? Yes _____ No _____
8) How many bedrooms are in your unit? _________
9) Have you had a change in family composition since your last recertification?
Yes _____ No _____
10) What type of change has occurred in your unit? ________________________________
_______________________________________________________________________
11) Did you report this change of family members at the time the change took place?
Yes _____ No _____
12) Did the person who moved out or moved in have a source of income?
Yes _____ No _____ If yes, did you report this source of income to the HACP?
Yes _____ No _____
13) Did you report this change in income to the HACP? Yes _____ No _____
14) Do you plan to remain in your present unit? Yes _____ No ___
15) IF YOU ARE TERMINATING YOUR LEASE, YOU ARE REQUIRED TO SEND A
LETTER OF TERMINATION BY CERTIFIED MAIL, IN ACCORDANCE WITH THE
LEASE TERMS TO YOUR LANDLORD AND RETURN A COPY OF THE LETTER
AND CERTIFIED MAIL RECEIPT ALONG WITH THIS PACKET.
16) Have you or any family member engaged in drug related criminal activity or violent criminal
activity? Yes _____ No _____ If Yes, explain: __________________________________
SIGN AND DATE THIS FORM. THIS OFFICE MUST HAVE YOUR PHONE NUMBER,
EVEN IF IT IS AN UNLISLTED NUMBER.
_____________________________________
Tenant Signature
_____________________________________
_______________________________
Address City, State, Zip
_____________________________________
________________________________
Phone Number Date
Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
ATTACHMENT
APPLICA
NT/TENANT CERTIFICATION
APPLICA
NT(S) TENANT(S) STATEMENT
I/We certify that the information* given to the PITTSBURGH HOUSING AUTHORITY on
household composition, income, net assets, allowances and deductions is accurate and
complete to the best of my/our knowledge and belief. I/We understand that false
statements or information are punishable under Federal Law. (Add reference to State
Law if applicable.) I/We also understand that false statements or information are
grounds for termination of housing assistance and termination of tenancy.
X____________________________________
X___________________________
Signature of Head of Household Date
X______________________________________ X__
_________________________
Signature of Spouse Date
If you believe you have been discriminated against, you may call the Fair Housing and
Equal Opportunity National toll-free hotline at 1-800-669-9777. (Within the Washington
D.C. Metropolitan Area, call 202-708-4252.
*After verification by this Housing Agency, the information will be submitted to the
Department of Housing and Urban Development on form HUD-50058 (Tenant Date
Summary), a computer-generated facsimile of the form or on magnetic tape. See the
Federal Privacy Act Statement for more information about its use.
OMB
Control # 2502-0581
Exp. (
02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
In
structions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant
Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Pr
ivacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
HOUSING CHOICE VOUCHER PROGRAM
200 ROSS STREET, STE 705
PITTSBURGH, PA 15219
HCV APPLICATION
NAME: _________________________________________________________
CURRENT ADDRESS: ____________________________________________ APT. #________________
CITY, STATE, ZIP CODE: __________________________________________
HOME PHONE #_______________ HEAD OF HOUSEHOLD WORK #_______________ SPOUSE WORK # _______________
LIST NAMES, ADDRESSES AND PHONE NUMBERS OF TWO RELATIVES OR FRIENDS WHO GENERALLY KNOW HOW TO CONTACT YOU.
1. NAME: _____________________________________ 2. NAME: ________________________________________
ADDRESS ______________________________________ ADDRESS ________________________________________
PHONE # _______________________________________ PHONE # ________________________________________
HOUSEHOLD COMPOSITION AND CHARACTERISTICS
List the Head of Household and all other members who will be living in the assisted unit. Please give the relationship of each family member to the head.
MEMBER
MEMBER’S FULL NAME
RELATIONSHIP
BIRTH DATE
BIRTH PLACE
AGE
SEX
SOCIAL SECURITY #
HEAD
1
2
3
4
5
6
Does anyone live with you now who is not listed above? □ Yes □ No If Yes, please explain: _______________________________
Is the Head, Spouse or Co-head of this Household disabled? □ Yes □ No If Yes, your family may be eligible for additional income
deductions, housing choices or preferences. HACP may request documentation that your disability meets HUD’s definition of disabled in order
to verify this status.
Is any member of the Household disabled? □ Yes □ No If Yes, your family may be eligible for additional income deductions or
housing choices. HACP may request documentation that your disability meets HUD’s definition of disabled in order to verify this status.
Does anyone in your Household need special communication assistance due to a disability? _______________________________________
Identify any special housing needs (reasonable accommodation) required as a result of the disability:
__________________________________________________________________________________________________________________
INCOME INFORMATION
Please answer each of the following questions. For each “Yes” answer, please provide the details in the chart in this section.
YES NO
1. Is any member of your household employed full-time, part-time, or seasonally? ………………………………………………. □ □
2. Does any member of your household work for someone who pays them in cash?…………………………………………….. □ □
3. Does any member of your household now receive, or expect to receive unemployment benefits?…………………………… □ □
4. Does any member of your household now receive or expect to receive child support?………………………………………… □ □
5. Is any member of your household entitled to child support that he/she is not receiving? ……………………………………... □ □
6. Does any member of your household now receive or expect to receive alimony payments? ……………………………….... □ □
7. Is any member of your household entitled to alimony payments that he/she is not receiving? ……………………………….. □ □
8. Does any member of your household now receive or expect to receive welfare assistance? …………………………………. □ □
9. Does any member of your household now receive or expect to receive Social Security benefits? ……………………………. □ □
10. Does any member of your household now receive or expect to receive income from a pension or annuity? ………………. □ □
11. Does any member of your household receive regular cash contributions from individuals not living in the unit or from
agencies? ………………………………………………………………………………………………………………………………. □ □
12. Does any member of your household receive income from assets including interest on checking or savings accounts,
interest and dividends from certificates of deposit, stocks or bonds, income from the rental of property? ………………… □ □
13. Is any member of your household over the age of 18? If so list their income below. ……………………………………….. □ □
14. Have you or any household member engaged in drug related criminal activity or violent criminal activity? ………………. □ □
If yes, please explain and give dates: _____________________________________________________________________________
For each type of income that your household receives, give the source of the income and the amount that can be expected from the source
during the next 12 months.*
*If additional space is needed, please list on a separate sheet of paper.
ASSET INFORMATION
List all checking and savings accounts (including IRA’s, Keogh accounts, and Certificates and Deposit) of all household members, including
assets or property sold or given away for less than their worth during the past two years.
FAMILY MEMBER
BANK NAME
ACCOUNT NAME
CURRENT BALANCE
*If additional space is needed, please list on a separate sheet of paper.
List value of all stocks, bonds, trusts, pension contributions, or other assets:
_____________________________________________________________________________________________________________________________
Do you own a home or other real estate? □ Yes □ No
Have you sold or given away real property or other assets in the past two years? □ Yes □ No If Yes, what is the current market
value of the assets? __________________________________________________________________________________________________
EXPENSES
Do you pay for childcare for children 12 years and under, which enables you or another family member to work, seek work or go to school?
□ Yes □ No If Yes, list names and ages of children: ______________________________________________________________
Address, and phone number of child care provider: _________________________________________________________________________
Weekly cost of Child Care: __________________________ Name of member enabled to work, seek work or go to school: ________________
__________________________________________________________________________________________________________________
Does any person or agency reimburse you or help you with child care costs? □ Yes □ No If Yes, please list the name(s) or the
persons and agencies: _______________________________________________________________________________________________
___________________________________________________________________________________________________________________
Families with a Person with a Disability as part of its family composition only:
Do you pay for a care attendant, service animal or any equipment for the family member with a disability necessary to permit that person or
someone else in the family to work?
□ Yes □ No If Yes, describe expenses:_________________________________________________________________________
Families where the Head, Co-Head or Spouse are Disabled and/or Elderly (62 years of age or older) only:
Do you have Medicare or Medicaid? □ Yes □ No If Yes, what is your Medicare/Medicaid) premium? (per year or monthly)
$__________________
Do you have any other type of medical insurance? □ Yes □ No If Yes, give policy number and carrier’s name: ________________
__________________________________________________________________________________________________________________
Do you expect to have any out of pocket medical expenses during the next 12 months? □ Yes □ No
COMMENTS/ADDITIONAL INFORMATION: ______________________________________________________________________________
________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
APPLICANT CERTIFICATION: I/We certify that the information given to the Housing Authority of the City of Pittsburgh on household
composition, income, net family assets, and allowances and deductions is accurate and complete to the best of my/our knowledge and belief.
I/We understand that false statements or information are punishable under Federal Law.
Signature of Head:
X ____________________________________________________
Date: X ________________________
Signature of Spouse: X ____________________________________________________ Date: X ________________________
NOTICE TO APPLICANTS: If you believe you have been discriminated against, you may call the Equal Opportunity National Toll-Free Hotline
at 800-424-8590.
FAMILY MEMBER
SOURCE OF INCOME/TYPE OF INCOME
ANNUAL INCOME
NOTICE: In compliance with Section 504 of the Rehabilitation Act of 1973 as amended, the Housing Authority of the City
of Pittsburgh does not discriminate on the basis of handicap (physical or mental) in the admission of or access to public
housing, or in the treatment of employees or applicants for employment. Any discrimination on this basis is illegal.
OMB C
ontrol # 2502-0581
Exp. (
02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Ins
tructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant
Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Pri
vacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
ASSET CHECKLIST
All family members 18 years or older listed on your application having any of the following assets
must sign and date form.
If yes, please complete this form and provide current statements/verifications for all assets
listed. If Yes, please check ______
If no, please mark the information below with “N/A”. If No, please check ______
Addi
tional forms for additional accounts can be obtained from the Section 8, Housing Choice Voucher
Program Department at your request.
Checking Accounts
Name(s) on Account: _________________________________________________________
Name and Address of Bank: ____________________________________________________
Balance: ______________________________Annual Interest: _______________________
Savings Accounts
Name(s) on Account: _________________________________________________________
Name and Address of Bank: ____________________________________________________
Balance: ______________________________Annual Interest: _______________________
Credit Union Accounts
Name(s) on Account: _________________________________________________________
Name and Address of Bank: ____________________________________________________
Balance: ______________________________Annual Interest: _______________________
Certificates of Deposit Accounts
Name(s) on Account: _________________________________________________________
Name and Address of Bank: ____________________________________________________
Balance: ______________________________Annual Interest: _______________________
Stocks
Name(s) on Stock: ___________________________________________________________
Name of Stock: ______________________________________________________________
Number of Shares: ___________________________________________________________
Savings Bonds
Name(s) on Bonds: ___________________________________Value: _________________
Property Owner
Name(s) on Property: _________________________________________________________
Address of Property: __________________________________________________________
Fair Market Value of Property: ___________________________________________________
I do hereby certify that all information I have provided is complete and accurate. I am aware
that submitting false information is fraud and may result in loss of Housing Assistance,
assessment of fines and/or imprisonment.
Signature: ____________________________________ Date: _________________________
click to sign
signature
click to edit
Original is retained by the requesting organization.
form HUD-9886
(07/14)
ref. Handbooks 7420.7, 7420.8, & 7465.1
Authorization for the Release of Information/
Privacy Act Notice
to the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA) exp. 07/31/2017
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termi-
nation of benefits is subject to the HA’s grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have re-
ceived during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited to the wage and self employment information and pay-
ments of retirement income as referenced at Section 6103(l)(7)(A)
of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is
limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and divi-
dends). I understand that income information obtained from these
sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD and the Housing Agency/Authority (HA) to request verifi-
cation of salary and wages from current or previous employers; (2)
HUD and the HA to request wage and unemployment compensa-
tion claim information from the state agency responsible for
keeping that information; (3) HUD to request certain tax return
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
verification of income information. Therefore, HUD or the HA
may request information from financial institutions to verify your
eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household’s income, in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. HUD and the HA may participate in computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose of determining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or im-
proper uses of the income information that is obtained based on the
consent form. Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become 18 years of age.
PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date) (Full address, name of contact person, and date)
U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing
Housing Authority of the City of Pittsburgh
200 Ross Street
Pittsburgh, PA 15219
Caster Binion, Executive Director
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
click to sign
signature
click to edit
click to sign
signature
click to edit
Original is retained by the requesting organization.
form HUD-9886
(07/14)
ref. Handbooks 7420.7, 7420.8, & 7465.1
Signatures:
_____________________________________________ ______________
Head of Household Date
___________________________________________
Social Security Number (if any) of Head of Household
__________________________________________________ _______________
Spouse Date
__________________________________________________ _______________
Other Family Member over age 18 Date
__________________________________________________ _______________
Other Family Member over age 18 Date
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for
the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that
receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first
independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In
addition, I must be given an opportunity to contest those determinations.
This consent form expires 15 months after signed.
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
Penalties for Misusing this Consent:
HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of
information collected based on the consent form.
Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully
requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more
than $5,000.
Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against
the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information
by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair
Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and
participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and
other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family
will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring
HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.
This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory
investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted
or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,
and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members
six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide
any of the requested information may result in a delay or rejection of your eligibility approval.
click to sign
signature
click to edit
Housing Choice Voucher Program
200 R
oss Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090; fax 412-456-5224
TTY: 412-201-5384
www.hacp.org
SELF-CERTIFICATION FORM
(Assets of less than $5,000)
I, ____________________________________ (Insert Name
of Tenant) self-certify that my accumulated and total
household assets are below $5,000. The provision for self-
certification is to simplify the requirements associated with
determining a participant’s annual income (24CFR 5.609(b)
(3), 982.516(a) (2) (ii), 960.259(c)).
I further understand that this provision has been extended until
further notice from the Department of Housing and Urban
Development (HUD).
___________________ _________________
Signature of Tenant Date
___________________ _________________
Signature of HACP Staff Date
Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes
per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays
a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 10/31/2019.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
Public Housing (24 CFR 960)
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
Section 8 Moderate Rehabilitation (24 CFR 882)
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e.
, abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
OMB No. 2577-0266 Expires 10/31/2019
08/2013
Form HUD-52675
click to sign
signature
click to edit
click to sign
signature
click to edit
2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date
or such other period consistent with State Law.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD
, subject to 24 CFR Part 16.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature Date
Printed Name
OMB No. 2577-0266 Expires 10/31/2019
08/2013
Form HUD-52675
Housing Authority of the City of Pittsburgh
200 Ross Street, Suite 705
Pittsburgh, PA 15219
click to sign
signature
click to edit
Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes
per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays
a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 10/31/2019.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
Public Housing (24 CFR 960)
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
Section 8 Moderate Rehabilitation (24 CFR 882)
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e.
, abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
OMB No. 2577-0266 Expires 10/31/2019
08/2013
Form HUD-52675
2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date
or such other period consistent with State Law.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD
, subject to 24 CFR Part 16.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature Date
Printed Name
OMB No. 2577-0266 Expires 10/31/2019
08/2013
Form HUD-52675
Housing Authority of the City of Pittsburgh
200 Ross Street, Suite 705
Pittsburgh, PA 15219
“Keep this copy”
“Keep this copy”
THE RESIDENT EMPLOYMENT PROGRAM
PROGRAM DESIGN
The Resident Employment Program is a program developed by the Housing Authority City of
Pittsburgh (Department of Resident Self Sufficiency) to empower residents to enter into the
workforce. This program is to assist residents with resources to become economically self-
sufficient.
NEIGHBORHOOD SERVED
The Resident Employment Program is responsible for serving all the Housing Authority City of
Pittsburgh’s Public Housing Communities and HCV residents.
HOURS OF OPERATION
The Resident Employment Program hours of operation are Monday – Friday 8:00 am – 5:00 pm.
Every 3
rd
Wednesday of the month, 10:00 am – 7:00 pm (Late hours).
RESIDENT EMPLOYMENT PROGRAM’S FUNCTIONS
Hold recruitment sessions for community members who need assistance in finding
employment twice a month at different HACP locations
Conduct application day twice a month
Hold annual mega job fairs for community members and Pittsburgh area employers.
Assist residents with job placement opportunities job referrals
Assist residents with writing resumes, cover letters and thank you letters
Assist and refer residents to enter into training and education programs
Assist residents with interviewing techniques and filling out applications properly
Provide residents with on-site employer interviews and job fairs
Assist residents with interview and work clothes
Make contact with Pittsburgh area employers
RESIDENT EMPLOYMENT CURRENT TRAINING PROGRAMS
Resident Employment Job Line X 1064
Pre-Orientation (Construction)
Green Jobs Training
Home Health Aide Training
GED Program
Computer Training
Drivers Education Training
Refer residents to BJWL Training
Refer residents to Job Corps Program
Application Day
Scheduled one on one interviews
SECTION 3 COMPONENTS
Assist public housing with employment in the construction field
Pre-Orientation and Orientation sessions are conducted for residents entering
the Section 3 Process.
Hiring Priority
• 1
st
– HACP leaseholders from communities where the work is performed
• 2
nd
– Residents from adjacent HACP communities
• 3
rd
– Residents from communities where work is being performed
• Residents from the City of Pittsburgh at-large
IN TERVIEW PARTNES
Family Resources, Inc.
PNC Bank
Addecco
Diversified Health Care
Job Corps
Bidwell Training Center
Mistick Construction
Honeywell
J&S Handyman Services
Service Masters
Housing Choice Voucher Program
200 Ross Street, Ste. 705
Pittsburgh, PA 15219
412-456-5090, fax: 412-456-5224
www.hacp.org
Assistance For Persons With Disabilities
The Housing Authority of the City of Pittsburgh can assist you in accessing suitable housing in
the Section 8/Housing Choice Voucher Program if your family includes a person with a
disability. We can help…..
1. R
equest a current listing of available units that are accessible or landlords who lease accessible units.
• The HACP will provide you with the most current listing of accessible units.
2. Ask to speak with a Housing Authority representative about your needs for accessible housing.
• A r
epresentative will discuss the housing options with you and assist you in determining your needs.
• Th
e representative will also assist you by contacting any known owners of accessible units to determine
if suitable vacancies exist.
• Th
e representative will provide contacts at other agencies that provide specialized services for persons
with disabilities.
3. If
you are a voucher holder and require additional time to search for housing, ask if you are eligible for a
special extension as reasonable accommodation by the Housing Authority.
• A r
epresentative will determine if you are eligible for an extension of search-time on your voucher up
to a total of 150 days.
4. If
the property you choose meets your accessibility needs and has a higher rent, you may qualify for a
higher Housing Authority assistance payment.
• Cont
act your Housing Authority representative if you locate a higher rent property that meets your
needs including those relating to your disability; and request a reasonable accommodation.
• Ba
sed upon the market value of the property and your special needs, the Housing Authority may
approve an exception payment standard, which can make the property more affordable.
5. If
you have any other special housing needs, the Housing Authority can help.
• The
Housing Authority can provide reasonable accommodations at any time for persons with
disabilities to use and enjoy its programs and housing options. You may request a reasonable
accommodation by simply contacting your Housing Authority representative.
• The representative can offer contacts at other agencies that provide specialized services for persons
with disabilities
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HCV Recertification Packet

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Completed 20 January 2022

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